Rectal Pain
Differential Overview
❑ Hemorrhoid
❑ Rectal fissure
❑ Prostatitis
❑ Anal fistula
❑ Pruritus ani
❑ Fecal impaction
❑ Coccydynia
❑ Perirectal abscess
❑ Infected pilonidal cyst
❑ Ulcerative proctitis
❑ Infective proctitis
❑ Proctalgia fugax
❑ Anal carcinoma
Diagnostic Approach
Tenesmus is a painful urge to defecate with little result.
Clinical Findings
Hemorrhoid Common presentations include bright red blood on the toilet tissue, a prolapsing rectal mass, itching, or thrombosis. The latter may be quite painful, with a firm, tender, bluish rectal nodule.
Rectal fissure There is usually pain on passing a bowel movement, and bright red blood will be seen on the toilet tissue. Fissures must be searched for carefully, stretching the skin at the anal verge around the complete
circumference.
Prostatitis The principal symptoms are constant perineal ache, fever, and dysuria. A boggy tender prostate is the sine qua non of diagnosis.
Anal fistula A fistula presents with persistent and irritating drainage of pus, blood, or mucous. An external opening is seen on close inspection. There is usually a history of perirectal abscess, Crohn disease, or radiation. It may not be painful if it is draining.
Pruritus ani Identifiable causes include pinworms (nocturnal itching), condyloma acuminata (filiform excrescences), contact dermatitis (mild itch worsened by use of topical agents), alkaline stools (severe diarrhea), psoriasis (intergluteal pinking and scaling patches elsewhere), and Candida (bright red lesions with satellites, in diabetics or immunocompromised hosts).
Fecal impaction Symptoms are diffuse abdominal discomfort or paradoxic diarrhea, but efforts to pass a bolus of desiccated stool are painful. The diagnosis is usually made by rectal exam.
Coccydynia Sitting or direct pressure over the coccyx is painful. The cause is usually trauma, due to a fall directly onto the buttocks.
Perirectal abscess Symptoms begin with a throbbing rectal pain, which develops into an exquisitely tender mass, palpable either externally or internally on rectal exam.
Infected pilonidal cyst Redness and tenderness develop around a sinus tract at the upper pole of the buttocks cleft. Purulent fluid may be expressed.
Ulcerative proctitis It presents with mucopurulent discharge, bleeding, and tenesmus. Systemic symptoms are rare when proctitis is confined to the
rectum.
Infective proctitis It occurs most prominently in gay males who engage in receptive anal intercourse. Gonococcal proctitis presents with a purulent rectal discharge. Herpes simplex proctitis is quite painful, accompanied by tenesmus, constipation, ulceration, and discharge.
Proctalgia fugax Fleeting (,30 minutes) rectal pain occurs with spasms and no abnormalities on examination.
Anal carcinoma Carcinoma may present with pruritus, mucoid drainage, and a change in bowel habits. A painless, hard, nodular or plaque-like mass is felt on rectal exam.
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.
More About Causes of Pale stool
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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